Skip to Main Content
Have library access? Log in through your library
The Truth About Health Care

The Truth About Health Care: Why Reform is Not Working in America

David Mechanic
Copyright Date: 2006
Published by: Rutgers University Press
Pages: 240
  • Cite this Item
  • Book Info
    The Truth About Health Care
    Book Description:

    The United States spends greatly more per person on health care than any other country but the evidence shows that care is often poor and inappropriate. Despite expenditures of 1.7 trillion dollars in 2003, and growing substantially each year, services remain fragmented and poorly coordinated, and more than 46 million people are uninsured. Why can't America, with its vast array of resources, sophisticated technologies, superior medical research and educational institutions, and talented health care professionals, produce higher quality care and better outcomes?In The Truth about Health Care, David Mechanic explains how health care in America has evolved in ways that favor a myriad of economic, professional, and political interests over those of patients. While money has always had a place in medical care, "big money" and the quest for profits has become dominant, making meaningful reforms difficult to achieve. Mechanic acknowledges that railing against these influences, which are here to stay, can achieve only so much. Instead, he asks whether it is possible to convert what is best about health care in America into a well functioning system that better serves the entire population.Bringing decades of experience as an active health policy participant, researcher, teacher, and consultant to the public and private sectors, Mechanic examines the strengths and weaknesses of our system and how it has evolved. He pays special attention to areas often neglected in policy discussions, such as the loss of public trust in medicine, the tragic state of long-term care, and the relationship of mental health to health care.For anyone who has been frustrated by uncoordinated health networks, insurance denials, and other obstacles to obtaining appropriate care, this book will provide a refreshing and frank look at the system's current and future dilemmas. Mechanic's thoughtful roadmap describes how health plans, healthcare professionals, policymakers, and consumer groups can work together to improve access, quality, fairness, and health outcomes in America.About the Author:

    eISBN: 978-0-8135-4115-0
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-xiv)
    David Mechanic
  4. Introduction
    (pp. 1-16)

    Why another book on our health care system? There is no lack of books, articles, and Internet sources telling us about the seemingly uncontrollable growth of health care demands and expenditures, the continuing and growing pressures of health costs on federal and state programs such as Medicare and Medicaid and on family household budgets, and the urgent need for reforms on many dimensions. It is nevertheless difficult to come to agreement on what should be done and through what policies. The core purpose of this book is to explore broadly the influences that make achieving consensus and implementing significant change...

  5. Part I Our Health Dilemma

    • [Part I Introduction]
      (pp. 17-18)

      The first section of this book examines the many sides of our health dilemma. The chapters that follow explore varying facets of our future health care challenges and how myriad interests influence the definitions of health and disease, approaches to prevention and treatment, and the financing and organization of health care itself. Many of the problems we face, such as high rates of uninsured persons, the uncontrolled expansion of new and untested technologies, the erosion of primary health care, and the neglect of mental health and long-term care, are in many ways products of how we as a nation organize...

    • Chapter 1 Is Reform Possible? The Need for Change and the Forces Against It
      (pp. 19-38)

      Having experienced serious back pain for more than forty years, despite back surgery some twenty-five years ago, I follow the back pain literature with much personal interest. In the 1980s I cochaired an Institute of Medicine (IOM) committee on pain, disability, and chronic illness and had an opportunity to work with many experts in the area and to study the literature. In our IOM report we noted the lack of strong evidence for back surgery in most instances of back pain and in the absence of a major neurological deficit.¹ We did note that while surgery often helps persons with...

    • Chapter 2 What Is Disease and What Should We Treat?
      (pp. 39-50)

      A major challenge to the financing and organization of health care is the continuing medicalization of the problems of everyday life. The definition of disease has always been a bit murky, tied to social, religious, and moral ideologies about desirable and undesirable behavior, with a tendency to characterize many behaviors that violated current social norms as sick. The debates, for example, about whether masturbation, homosexuality, and promiscuous behavior were diseases waxed and waned over the years as cultural ideas changed, but persons engaged in these behaviors were given many so-called treatments and were even institutionalized. With greater enlightenment we might...

    • Chapter 3 Saving Lives Individually or in Populations
      (pp. 51-66)

      Health and mortality vary dramatically from one place to other, reflecting social and cultural context even more than biological factors. We might ask, for example, why men in Chicago are thirty times more likely to perpetrate a homicide than men in England and Wales.¹ The overall trends in both contexts are similar. Both have much lower risk among women, rising risk in youth and young adulthood, and declining risk in older age. But the cross-national differences in prevalence dwarf all else. We can spend a great deal of money looking for a gene for violence, and biological factors undoubtedly contribute...

    • Chapter 4 The Murky Challenge of Mental Health
      (pp. 67-83)

      The term “mental health” is one almost everyone uses, but it has no clear or consistent meaning. The mental health specialty sector commonly refers to its domain as behavioral health, covering the provision of services for psychiatric disorders and substance abuse problems. Behavioral factors affect almost every aspect of health and health care, including the occurrence of health problems, people’s conceptions of sickness and what is wrong, decisions to seek help, cooperation and response to treatment, and the course and chronicity of illness. Mental health, broadly defined, is important to all aspects of medicine and medical care. Mental health is...

    • Chapter 5 The Activated Patient and the Doctors’ Dilemma
      (pp. 84-99)

      In his book,Overdosed America, John Abramson, now an instructor in medicine at Harvard, describes how he explained leaving his practice after twenty years to one of his longtime patients. He relayed his frustrations with unneeded routine tests, expensive drugs that were no better or safer than older medications, and the commercial spinning of clinical decisions and scientific evidence. He explained that many of his patients, influenced by drug advertisements and the media, were increasingly visiting him with strong ideas of what they wanted and became suspicious when he tried to convert them to other interventions. He noted, “Many were...

    • Chapter 6 The Neglect of Long-Term Care
      (pp. 100-112)

      Many of us who have experienced the deterioration and death of parents or loved ones when the care process breaks down, as it often does at the end of life, share some sense of helplessness and frustration. Being an experienced medical professional doesn’t necessarily help, because even expertise cannot counterbalance faulty systems that work against you. In a moving essay, Jerald Winakur, a geriatrician with thirty years experience and the medical director of a hospital skilled-nursing unit, describes his sense of loss and futility as his elderly father became increasingly disabled and demented. As Winakur notes, all of the complications...

  6. Part II The Struggle for Solutions

    • [Part II Introduction]
      (pp. 113-114)

      There is much consensus that major changes are required in our health care system, but there is also a great deal of disagreement about the way forward. Many interests seek to protect their own turf, and faced with actual choices for change, they often prefer the status quo, however deficient, to uncertainty and the prospect of losing ground. Achieving significant changes will require defining a broad middle ground where enough of the players see themselves as having something to gain.

      Everyone wants more quality unless they feel their ox is being gored. Thus, introducing and implementing quality systems requires getting...

    • Chapter 7 The Quest for Quality
      (pp. 115-129)

      Repeated studies going back over decades demonstrate that the quality of health care falls far short of what could be achieved. Medicine is a complex and ever-changing endeavor, and it is inevitable that there will always be significant gaps between what is theoretically possible and the actual provision of care in numerous settings, involving hundreds of millions of transactions. One need not think in utopian terms, however, to understand the magnitude of deficiencies and the mortality, illness, and disability that are avoidable even in a very imperfect system. Observations of avoidable errors in care have been enumerated over many decades,...

    • Chapter 8 Setting Fair Limits
      (pp. 130-142)

      In 1998 the marketing of Viagra, the first effective sexual-enhancement drug, brought the issue of rationing, a topic widely discussed among health care experts for many years, to a larger public. There have always been well-understood limits on some procedures seen as having no clear medical purpose, such as many cosmetic surgery procedures, but the introduction of Viagra posed more difficult policy issues about payment for enhancement drugs. Viagra, whatever its lifestyle-enhancement value, had a serious medical purpose in treating men with erectile dysfunction (ED) associated with aging and such conditions as prostate cancer, diabetes, and cardiovascular disease. ED is...

    • Chapter 9 Restoring Trust in the Health System
      (pp. 143-158)

      Opinion polling is often limited in a way that leaves much to the imagination and to the respondents’ interpretations. But in a national survey in 2002, the National Opinion Research Corporation posed a detailed question to respondents about their willingness to accept their physician’s judgment.¹ The survey asked:

      Imagine you’ve been experiencing headaches. You visit your doctor and talk to him about your symptoms. You also tell the doctor that you’ve been feeling a lot of stress lately. After doing a complete examination, the doctor decided that the headaches are probably due to stress. You want to have an MRI...

  7. Part III The Fork in the Road

    • [Part III Introduction]
      (pp. 159-160)

      Public views of the U.S. health care system have been monitored since 1986, and surveyors report that at any given time one-half to three-fifths of the population believes the system has good points but that major changes are needed to make it work better.¹ In 2003 only 11 to 13 percent reported that the system worked pretty well and that only minor changes were needed. In the same year, 30 percent believed the system needed to be completely rebuilt. In a national survey in August 2005, respondents ranked health care as the second most important problem that government needed to...

    • Chapter 10 The Challenge of Change
      (pp. 161-178)

      There is widespread agreement that major changes are needed in our health care system but little consensus on how to achieve them. Strong philosophical differences about the appropriate responsibilities of the public and private sectors, how care should be financed, the roles of consumers, providers, payers, government, interest organizations, and other issues discussed throughout this book divide policy makers, interested participants, and the general public. While some may await the next political opportunity to make the case for a major overhaul of the health care system and a program of national health insurance, neither our health policy history nor political...

    • Chapter 11 Steps in Our Health Future
      (pp. 179-188)

      It has been asserted frequently over the past several decades that significant reform of health care would not come until most Americans were unhappy with their health services and demanded major changes. At the time of Bill Clinton’s inauguration as president in 1993, the conditions seemed ripe for such change. Medical costs continued to escalate, more persons were losing their insurance, people felt locked into jobs to retain their health care coverage; Americans felt increasingly insecure about the economy, their jobs, and their health care coverage, and health reform had gained political momentum among the electorate. Although it appeared that...

  8. Notes
    (pp. 189-210)
  9. Index
    (pp. 211-228)
  10. Back Matter
    (pp. 229-229)